Medical Consent

WE ARE NOT A REPLACEMENT FOR EMERGENCY MEDICAL SERVICES. IF YOU HAVE A MEDICAL EMERGENCY, SEEK EMERGENCY MEDICAL CARE IMMEDIATELY IN PERSON, OR DIAL 911 OR YOUR LOCAL EMERGENCY NUMBER.

We may change these terms at any time, as required by law — including changing, adding or removing terms in response to legal, business, competitive or other circumstances.

Telehealth Consent

Telehealth is care that allows patients to access health services using electronic communications — such as audio-video interfaces, secure messaging and electronic form review — connecting you with licensed healthcare professionals in another location. The electronic systems used incorporate network and software security protocols to protect the confidentiality of your identification and clinical data, with measures to safeguard the data and ensure its integrity against intentional or unintentional corruption.

Expected benefits:

• Improved access to physician-guided care by enabling you to receive services across distances and between programs.
• More efficient medical evaluation and management.
• Access to the expertise of distant specialists.
• Maintained connections with established providers in other areas.

Possible risks. As with any medical service, telehealth carries potential risks, including but not limited to:

• In rare cases, transmitted information may be insufficient (for example, poor image resolution) for appropriate medical decision-making by the clinician.
• Delays in evaluation and treatment could occur due to equipment deficiencies or failures.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
• In rare cases, lack of access to complete medical records may result in adverse drug interactions, allergic reactions or other errors of judgment.

By consenting, I understand the following:

• The laws protecting the privacy and confidentiality of medical information also apply to telehealth, and no identifying information obtained through telehealth will be disclosed to researchers or other entities without my consent.
• I have the right to withhold or withdraw my consent to telehealth at any time without affecting my right to future care or treatment.
• I have the right to inspect all information obtained and documented during a telehealth interaction and may receive copies for a reasonable fee.
• A variety of alternative methods of care may be available to me, and I may choose one or more of them at any time.
• It is in my best interest to inform my clinician of any other healthcare providers involved in my care.
• I may expect the anticipated benefits of telehealth, but no results can be guaranteed or assured.

Patient consent to the use of telehealth. I have read and understand the information above regarding telehealth, have had the opportunity to discuss it with my clinician or designated clinical staff, and my questions have been answered to my satisfaction. I give my informed consent to the use of telehealth in my care, and I have been offered a copy of this form for my records. My continued use of the services constitutes my understanding and acceptance of these terms, and I authorize the use of telehealth in the course of my diagnosis and treatment.

HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. This is a plain-language summary; the complete text is our Notice of Privacy Practices. HIPAA places rules and restrictions on who may see or be notified of your Protected Health Information (PHI) — restrictions that do not include the normal exchange of information necessary to provide your care. Additional information is available from the US Department of Health and Human Services at www.hhs.gov.

We have adopted the following policies:

• Patient information is kept confidential except as necessary to provide services or to handle administrative matters related to your care appropriately — specifically including sharing with other healthcare providers, laboratories and payers as necessary and appropriate for your care. You agree to the normal procedures used for handling charts, records, PHI and related documents in the course of providing care.
• We may remind you of appointments and send communications about policy or procedure changes by telephone, email, mail or other convenient means, including means you request.
• We use vendors in the conduct of business who may access PHI and who must agree to abide by HIPAA confidentiality rules.
• You understand and agree to inspections and document review (which may include PHI) by government agencies or payers in the normal performance of their duties.
• You agree to bring privacy concerns or complaints to the attention of our Privacy Officer.
• Your confidential information will not be used for marketing or advertising of products, goods or services.
• We provide patients access to their records in accordance with state and federal law.
• We may change, add, delete or modify these provisions to better serve the needs of the practice and the patient. You may request restrictions on the use of your PHI and changes to certain policies, though we are not obligated to alter internal policies to conform to your request.

My continued use of the services constitutes my understanding and acceptance of the terms in this HIPAA information section and any subsequent policy changes. This consent remains in force from this time forward.

Financial Consent

I understand and accept that, in order to render services, a payment card may be kept on file and that any remaining balances for services rendered shall be paid in full. I authorize GEVITIX LAB [CONFIRM legal entity name] to submit on my behalf, and to release, any medical records or other information necessary to process my consultation order. Fee schedules and receipts for all professional services are available upon request.

I authorize GEVITIX LAB to make invoice changes and debit my account for orders placed, goods received and/or services rendered not fully covered by third-party vouchers or credits, and to charge my payment card for any unpaid balances due.

All programs are auto-renewing, and I consent to be charged automatically for any program I am part of unless I explicitly request cancellation before my payment is processed, in accordance with the Cancellation & Refund Policy. Refunds are governed exclusively by that policy. I certify that I am an authorized user of the payment card provided and agree to contact GEVITIX LAB to resolve any billing concerns before initiating a payment dispute.

Shipping Authorization

All prescription medications are dispensed according to state and federal law, with the approval of the pharmacist in charge and in compliance with all applicable requirements of the relevant medical boards and state boards of pharmacy. I disclaim and agree to hold GEVITIX LAB harmless for any delays or errors during the shipping process. Medication is considered dispensed, and the order completed, when it is signed out for shipping — not when it arrives via delivery.

My continued use of the services constitutes my understanding and acceptance of these terms, and I give permission for GEVITIX LAB to ship medication to the address provided in my intake form or any other address I provide.